Information Regarding Child/Youth and Incident

Attention: Please do not include the name of child/youth associated with this notification

Gender *

Age on Date of Incident *

Location of Incident (city, town) *

Province *

Specific Location *

If “Other”, please specify location

Home Community (please enter unknown if you do not know) *

Province *

Postal Code (A9A 9A9)

Please describe the circumstances (What, where, and when it happened, actions taken by the Service Agency) *

Additional Notes (For any additional information in regards to reporting and notification)

Submitted By

First Name *

Last Name *

Organization Email *

Contact person for further information

First Name *

Last Name *

Date of Notification Submission (mm/dd/yyyy) *

Notification Requirements

Attention:

You are required to provide both the young person and parent(s) with contact information for the Office of the Provincial Advocate for Children and Youth, within 14 days of the Incident. A confirmation of notification no longer needs to be submitted to the Advocate’s Office.

Service providers should maintain records that document that they have complied with the legal obligation to notify children and parents about the Office of the Provincial Advocate for Children and Youth, as the Advocate's office may request this confirmation at a later date as part of an individual or systemic investigation.

* These fields are required.

*Please print the form for your own records before submitting. A copy of the completed form will not be provided following submission.